https://orcid.org/0000-0002-7714-8869
Abstract
Background
This study aimed to determine the prevalence and correlates of self-reported cardiovascular diseases (SRCVDs) among adults in Ecuador.
Methods
National cross-sectional survey data of 4638 persons aged 18–69 years in Ecuador were analysed. Research data were collected with an interview-administered questionnaire, physical and biochemical measurements.
Results
The prevalence of SRCVDs was 8.7%, 8.5% among men and 8.9% among women. In adjusted logistic regression analysis, being Montubio (adjusted odds ratio-AOR: 1.66, 95% confidence interval-CI: 1.10–2.50), family alcohol problems (AOR: 1.78, 95% CI: 1.19–2.65), past smoking tobacco (AOR: 1.36, 95% CI: 1.02–1.81), and poor oral health status (AOR: 1.74, 95% CI: 1.19–2.54) were associated with SRCVD. In addition, in unadjusted analysis, older age, alcohol dependence, obesity, and having hypertension were associated with SRCVD.
Conclusion
Almost one in ten persons aged 18–69 years had SRCVD in Ecuador. Several associated factors, including Montubio by ethnicity, family alcohol problems, past smoking, and poor oral health status, were identified, which can be targeted in public health interventions.
Introduction
Globally, an estimated 17.9 million people died from Cardiovascular disease (CVDs) in 2016, representing 31% of all global deaths. Of these deaths, 85% are due to heart attack and stroke.Citation1 In persons 50 years and older in 2019, “ischaemic heart disease and stroke were the top-ranked causes of disability adjusted life years (DALYs).”Citation2 More than three-quarters of deaths from CVDs occur in low- and middle-income countries.Citation1 “Heart attacks and strokes are usually acute events and are mainly caused by a blockage that prevents blood from flowing to the heart or brain.”Citation1
In studies in the Americas, a study (60 years and older) in seven urban centres in Latin America and the Caribbean, the prevalence of self-reported cardiovascular disease (SRCVD) was 20.3%,Citation3 and in a study among persons aged 60 years and older in the highlands and coastal areas of Ecuador in 2009 found a prevalence of self-reported heart disease of 13.1% and stroke 6.4%.Citation4 In urban-rural sites (35–70 years) in Argentina, Brazil, Chile and Colombia the prevalence of SRCVD was 3.9%, 6.9%, 3.3%, and 3.8%, respectively.Citation5 In a national study in Brazil (18 years older) the SR stroke prevalence was 1.6%,Citation6 in Colombia (18–69 years) SRCVD 5.5%,Citation7 Mexico (50 years and older) the prevalence of SR stroke was 4.3% and angina 13.6%,Citation8 and in USA in 2016 (20 years plus), SRCVD (congestive health failure 3.4%, angina 3.0%, heart attack 4.4%, or stroke 3.9%).Citation9 In Nepal (24–64 years), 2% had major cardiovascular events,Citation10 in China (35–74 years) 3.3% in men and 3.6% in women SRCVD,Citation11 in Australia (≥25 years) (2007–2008) the prevalence of SRCVD (heart attack or stroke) was 4.5%.Citation12 To our knowledge, we could not find national information on SRCVD in Ecuador.Citation13,Citation14 CVDs contribute to 24% of mortality in 2016 in Ecuador.Citation15 Using the mortality national registry in Ecuador, the myocardial infarction mortality rate increased from 51 in 2012 to 157 in 2016 deaths per 100,000,Citation16 and mortality due to ischemic heart disease increased in Ecuador in the period 2001–2016.Citation17 Ecuador’s population (16.9 million) consists of a mixture various ethnic groups, ranging from Mestizo (71.9%) to Afro Ecuadorian (4.3%).Citation18
Factors associated with SRCVD include sociodemographic factors, behavioural and biological CVD risk risk factors. Sociodemographic factors associated with SRCVD include, older age,Citation9,Citation19,Citation20 men,Citation9,Citation20 women,Citation4,Citation19 low socioeconomic status,Citation21 lower education,Citation6,Citation9,Citation20 and ethnicity.Citation22 Behavioural CVD risk factors associated with SRCVD may include, smoking/tobacco use,Citation3,Citation6,Citation20 past smoking,Citation4 physical inactivity,Citation4,Citation6,Citation23 inadequate or low fruit and vegetable consumption,Citation10,Citation23 high intake of sodium and sodium chloride (regular salt),Citation24,Citation25 and psychological distress.Citation12 Biological CVD risk factors associated with SRCVD may include, hypertension,Citation3,Citation19–Citation23,Citation26,Citation27 diabetes,Citation3,Citation6,Citation20–Citation23,Citation26 obesity,Citation3,Citation4,Citation6,Citation21,Citation23,Citation26 abnormal cholesterol values,Citation19 and poor oral health (edentulism).Citation28 This study aimed to determine the prevalence and correlates of SRCVDs in a national population-based survey among adults in Ecuador in 2018.
Method
Sample and Procedures
This is a secondary analysis conducted using nationally representative population-based and cross-sectional data (18–69 years old) from the “2018 Ecuador STEPS survey.”Citation29 The 2018 Ecuador STEPS survey data and more detailed sampling methods can be found elsewhere.Citation30 Briefly, using a three-stage cluster sampling method, at the first stage primary sampling units (PSUs) were selected by stratum, at the second stage within each PSU selected in the first stage 12 occupied households were selected, and at the third stage, one participant (18–69 years) was selected from each household.Citation30 Selected individuals were assessed with an interview-administered questionnaire, physical and biochemical measurements.Citation30 Research data were collected using electronic tablet devices.Citation30 The “Ethical Review Committee of the Ecuador Ministry of Health” approved the study.Citation30
All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all participants included in the study.
Measures
Outcome variable: History of CVDs was assessed with the question, “Have you ever had a heart attack or chest pain from heart disease (angina) or a stroke (cerebrovascular accident or incident)?” (Yes, No).Citation30
Sociodemographic covariates included age, sex, highest level of formal education, and ethnicity.Citation30
Behavioural covariates included current and past smoking tobacco, daily servings of fruit and vegetable intake, and “low, moderate or high physical activity based on the Global Physical Activity Questionnaire”.Citation30,Citation31 Salt intake was assessed with the item, “Do you add salt to food at the table?”Citation30 Responses were trichotomized into 1=never, 2=raley or sometimes, and 3=often or always. Alcohol dependence was sourced from the “Alcohol Use Disorder Identification Test=AUDIT” (items 4–6, ≥4 total scores).Citation32 Alcohol family problems was sourced from the item, “During the past 12 months, have you had family problems or problems with your partner due to someone else’s drinking?” (1=yes: > monthly to 4=once or twice).Citation30
Biological covariates included measured Body Mass Index (BMI) classified as “<18.5kg/m2 underweight, 18.5–24.4kg/m2 normal weight, 25–29.9kg/m2 overweight and ≥30 kg/m2 obesity”.Citation33 Hypertension or raised blood pressure (BP) was defined as “systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg or where the participant is currently on antihypertensive medication”.Citation34 Diabetes was defined as “fasting plasma glucose levels ≥7.0 mmol/L (126 mg/dl); or using insulin or oral hypoglycaemic drugs; or having a history of diagnosis of diabetes”.Citation35 Raised total cholesterol was defined as “fasting TC ≥5.0 mmol/L or currently on medication for raised cholesterol”.Citation35 Self-rated oral health status (AROH) was sourced from two items, 1) “How would you describe the state of your teeth, and 2) How would you describe the state of your gums?”Citation30 Poor SROH was defined as “having poor or very poor status of teeth and/or gums, and good oral health as having average, good, very good or excellent status of teeth and/or gums”, in line with previous research.Citation36 Cronbach alpha’s for the two item SROH scale was 0.74 in this sample.
Data Analysis
Considering the clustered study design, all statistical analyses were done using “STATA software version 14.0 (Stata Corporation, College Station, TX, USA).” Unadjusted and adjusted logistic regression was used to calculate predictors of SRCVD. Variables with p-values <0.1 in univariate analysis (age group, educational level, ethnicity, family alcohol problems, smoking status, alcohol dependence, body weight status, hypertension, and self-rated oral health) were included in the final adjusted model. P-values of below 0.05 were accepted as significant and missing values were excluded from the analysis.
Results
Sample and Cardiovascular Diseases Prevalence Characteristics
The sample included 4,638 adults (18–69 years; with 39 median age), 58.1% were female, 30.5% had higher education, and majority (78.9%) belonged to the Mestizo ethnic group. The study response rate was 69.4%.Citation30 One in five participants (24.7%) had low physical activity, 13.7% currently smoked tobacco, 11.8% were dependent on alcohol use, 7.0% had alcohol family problems, 58.8% had 1 or less serving of fruit and vegetables a day, and 12.45 often or always added salt to their meals. One in four respondents (25.7%) had obesity, 20.5% hypertension, 7.1% diabetes, 34.8% raised total cholesterol, and 9.7% poor oral health. The prevalence of SRCVDs was 8.7%, 8.5% among men and 8.9% among women (see ).
Table 1 Sample and Cardiovascular Disease Characteristics Among Adults, Ecuador, 2018
Associations with Self-Reported Cardiovascular Disease Prevalence
In adjusted logistic regression analysis, Montubio (Adjusted Odds Ratio-AOR: 1.66, 95% Confidence Interval-CI: 1.10–2.50), family alcohol problems (AOR: 1.78, 95% CI: 1.19–2.65), past smoking tobacco (AOR: 1.36, 95% CI: 1.02–1.81), and poor oral health status (AOR: 1.74, 95% CI: 1.19–2.54) were associated with SRCVD. In addition, in unadjusted analysis, older age, alcohol dependence, obesity, and having hypertension were associated with SRCVD (see ).
Table 2 Multivariable Associations with Self-Reported Cardiovascular Disease
Discussion
In this nationally representative sample of adults (18–69 years) in Ecuador, the prevalence of SRCVD (8.7%) was higher than in Argentina (3.9%, 35–70 years), Brazil (6.9%, 35–70 years), Chile (3.3%, 35–70 years) and Colombia (3.8%, 35–70 years),Citation5 in Brazil (SR stroke, 1.6%, 18 years older),Citation6 Colombia (5.5%, 18–69 years),Citation7 in Nepal (SRCVD, 2.0%, 24–64 years),Citation10 in China (SRCVD, 3.5%, 35–74 years),Citation11 in Australia (SRCVD, 4.5%, ≥25 years),Citation12 and USA (SR congestive health failure 3.4%, angina 3.0%, heart attack 4.4%, or stroke 3.9%, 20 years and older).Citation9 However, it should be noted that the prevalence rates of SRCVD are difficult to compare because of different measurements and different age groups. The high prevalence of SRCVD found in Ecuador calls for community-based massive education campaigns and health care provision of people with CVD, including the identification of a cerebral-vascular event and emergency care.Citation3,Citation37
Consistent with previous research,Citation9,Citation19,Citation20 older age (45–69 years) was positively associated with SRCVD in unadjusted analysis. Some previous studies found sex differencesCitation4,Citation9,Citation19,Citation20 in the prevalence of SRCVD, while in our study sex differences were not reaching significance. Other research found an association between low socioeconomic status or lower educationCitation6,Citation9,Citation20,Citation21 and SRCVD, while this survey did not show such associations. Compared to Mestizo Ecuadorean, Montubio Ecuadorean were more likely and Amerindian less likely (marginally significant) to have SRCVD. In a previous study among Amerindians in Ecuador, a low prevalence of atrial fibrillation was found, which can be explained by, both, “racially determined short stature and frequent dietary oily fish intake.”Citation38 The most significant predictors of the increasing mortality rate from myocardial infarction in Ecuador were living in the coast belonging to a mixed race.Citation16 The Montubio (“an aboriginal mestizo group that originates from the coastal part of Ecuador”)Citation18 may form part of this mortality rate from myocardial infarction. In the study among older adults in Ecuador,Citation4 people living on the coast had an increased risk of heart disease and stroke compared to those in the highlands.
In agreement with previous research,Citation12,Citation39,Citation40 this study showed that psychosocial stress in the form of alcohol family problems was associated with SRCVD. Stress can increase the cerebrovascular disease risk by modulating sympathomimetic activity, affecting the blood pressure reactivity, cerebral endothelium, coagulation, or heart rhythm.Citation39 In line with former research,Citation3,Citation4,Citation6,Citation20 past tobacco use was positively associated with SRCVD. In a systematic review and meta analysis the importance of smoking as an independent risk factor for stroke was confirmed.Citation41 Contrary to expectation,Citation4,Citation6,Citation10,Citation23–Citation25 physical inactivity, inadequate or low fruit and vegetable consumption and frequent salt consumption were not associated with SRCVD in this study. Similarly to a study in Nepal,Citation10 the consumption of fruit and vegetables was very low in this study, but was unlike in the Nepal study not associated with SRCVD.
Consistent with former research,Citation3,Citation4,Citation6,Citation19–Citation23,Citation26,Citation27 this survey showed in univariate analysis an association between hypertension and obesity with SRCVD. Unlike some studies,Citation3,Citation6,Citation19–Citation23,Citation26 this study did not find significant associations between diabetes, raised cholesterol and SRCVD. In line with some previous research,Citation28 poor oral health (edentulism) was positively associated with SRCVD. Periodontal diseases have been shown to be associated with systematic diseases, such as CVD.Citation42
The strength of the study includes a nationally representative sample of adults in Ecuador and the use of a standardized STEPS survey methodology and measurements. Study limitations include the cross-sectional design, the assessment of some variables, including CVD by self-report, and that certain relevant variables, such as psychological distress, were not assessed. Previous research compared self-reported versus hospital-coded diagnosis of CVD, and found SRCVD valid for epidemiological studies.Citation43 Further, the study did not assess the duration of having a CVD and the CVD type, which prevents us from establishing a trend between time of CVD diagnosis and health risk behaviours. The study participants only included those that had survived CVD, and excluded those with CVD who had died prior to the survey, increasing the possible underestimates of our figures.Citation44
Conclusion
Almost one in ten persons aged 18–69 years reported having been diagnosed with CVD in Ecuador. Several associated factors for CVD, such as being Montubio, family alcohol problems, past smoking tobacco, and poor oral health status were identified, which can be targeted in public health interventions.
Acknowledgment
The data source, the World Health Organization NCD Microdata Repository (URL: https://extranet.who.int/ncdsmicrodata/index.php/catalog), is hereby acknowledged.
Disclosure
The authors report no conflicts of interest in this work.
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